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614 General Principles Of Anesthesia > Last FREAKING Week 15 - Potpourri > Flashcards

Last FREAKING Week 15 - Potpourri Flashcards

1
Q

What is Postoperative Nausea and Vomiting (PONV)?

A

Nausea, retching, or vomiting in the postanesthesia care unit (PACU) and in the immediate 24 hour postoperative hours.

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2
Q

What is Post discharge nausea and vomiting (PDNV)?

A

Symptoms that occur after discharge for outpatient procedures.

(She said it is after the 24 hours).

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3
Q

is a major causes of dissatisfaction after anesthesia and frequent cause of unexpected hospital admission after ambulatory surgery.

A

Prolonged vomiting

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4
Q

T/F: Patients often rate PONV as worse than postoperative pain

A

True

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5
Q

T/F: Patients often rate PONV as worse than postoperative pain

A

True

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6
Q

POV affects ______ % of all surgical patients,

incidence of nausea is ______%

and

PONV in high risk patients can be up to _______%

A

30;

50

80

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7
Q

Risk of PONV in Adults

A

Female
Opioid analgesia
GA*

Hx of PONV or motion sickness.
Age: younger
Non-smokers
Duration of sx
Surgery type.

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8
Q

PONV is associated (2) with :

A
  • delayed discharge from the PACU
  • increased admission
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9
Q

Risk for PONV in adults using the Apfel Simplified Risk Score:

How does it work?

A

0, 1, 2, 3, and 4 risk factors correspond to PONV risks of approximately 10%, 20%, 40%, 60%, and 80%, respectively

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10
Q

Risk Factor Scores for PDNV

A

Female Gender
History of PONV
Age <50
Use of opioids in PACU
Nausea in PACU

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11
Q

Postdischarge Nausea and Vomiting (PDNV) is associated with (2):

A
  • delayed return to work/normal activities.
  • Emergency Room (ER) visits and hospital readmission
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12
Q

Risk score for PDNV in adults using the Apfel Simplified Risk Score:

How does it work?

A

0, 1, 2, 3, 4, and 5 risk factors correspond to PDNV risks of approximately 10%, 20%, 30%, 50%, 60%, and 80%, respectively

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13
Q

Potential Consequences of PONV (7):

A
  • Increased cost
  • Increased admission rates (ambulatory care)
  • Suture dehiscence
  • Aspiration
  • Increased ICP
  • Pneumothorax
  • Patient Dissatisfaction
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14
Q

Factors that increase PONV: (9)

A
  • Duration of anesthesia
  • Anesthetic technique
  • Volatile anesthetics
  • Nitrous, neostigmine?, Opioids, Methohexital, Etomidate
  • Hypotension, Dehydration, Fasting
  • Experience of the anesthetist
  • Placement of airways
  • Hypercarbia, Gastric insufflation
  • Sympathetic stimulation
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15
Q

Types of surgery that can cause PONV in adults:

A

Cholecystectomy
Gynecologic (GYN)
Laparoscopic Procedures
Eye and Ear surgery
Shoulder?

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16
Q

Types of surgery that can cause PONV in children:

A
  • Inguinal, scrotal or penile procedures
  • Strabismus surgery
  • A denotonsillectomy

ISA is my cousin’s daughter! she is always vomiting!!

(Dr. R said these also fit for adults)

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17
Q

The pathophysiology of PONV involves central and peripheral mechanism.

5 principle neurotransmitter receptors are involved:

A
  • Anticholinergic/Muscarinic M1
  • Dopamine D2
  • Histamine H1
  • 5-hydroxytryptamine (HT) 3 serotonin
  • Neurokinin 1 (NK1) or
  • Substance P

All of these receptors may be targets for prevention or treatment of PONV

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18
Q

The chemoreceptor Zone (CTZ) is located where?

and what two-neurotransmitters does it involve?

A
  • in 4th ventricle in the area postrema.
  • Dopamine D2 and 5HT-3
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19
Q

What drugs and toxins is the the CTZ susceptible to? and why?

A

(Chemo), anesthetic agents, opioids.

  • Not protected by the blood brain barrier
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20
Q

What is the vestibular system responsible for?
and what are the neurotransmitter involved?

A
  • Motion and equilibrium, middle ear
  • Histamine H1 and Muscarinic M1
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21
Q

Where is the vomiting center?

A

in nucleus tractus solitarius in postrema and lower pons.

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22
Q

What in the GI tract can cause PONV?

A
  • Afferent vagus nerve (stimulation).
  • Enterochromaffin cells release serotonin
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23
Q

Areas in the body involved with PONV:

A
  • CTZ
  • Vestibular system
  • Vomiting center
  • Cerebral cortex
  • GI tract
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24
Q

Strategies to Reduce Baseline Risk of PONV:

A
  • Avoidance of GA by the use of regional anesthesia.
  • Use of propofol for induction and maintenance of anesthesia.
  • Avoidance of nitrous oxide in surgeries lasting over 1 hr.
  • Avoidance of volatile anesthetics.
  • Minimization of intraoperative and postoperative opioids.
  • Adequate hydration.
  • Using sugammadex instead of neostigmine for the reversal of neuromuscular blockade.
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25
Q

Prevention of PONV includes:

A
  • Monotherapy or Combination (additive)
  • Anesthesia technique (Regional, TIVA)
  • Opioid sparing/Postop pain control
  • Supplemental O2 concentration
  • Avoid hypotension
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26
Q

Opioid sparing/Postop pain control medications:

A

Celebrex and
Neurontin,
Tylenol (IV or PO)
NSAIDS
Ketamine
Precedex
Robaxin

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27
Q

Treatment/Pretreatment of PONV durgs:

and others not used as much?

A
  • Scopolamine patch
  • Reglan
  • Decadron
  • Zofran
  • Propofol
  • Vistaril/ Ephedrine

Others:
- Fluids?
- Phernergan (Phenothiazine)
- Butyrophenones (droperidol and haldol).

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28
Q

Scopolamine MOA and application.

A
  • Competitive inhibitor at muscarinic sites.
  • 2 hours prior to induction of anesthesia and remove 24 hours after use
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29
Q

Reglan - MOA?

A

dopamine 2 antagonist

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30
Q

Decadron class and dose.

A

Decadron 4-8 mg on induction (steroid)

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31
Q

Zofran - MOA and dose?

A
  • 5-HT3 receptor antagonist.
  • 4 mg at the end of surgery.
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32
Q

Vistaril dx class and dose?

A
  • Histamine 1 antagonist.
  • Vistaril/Ephedrine 25/25 mg IM
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33
Q

Neurokinin 1/Substance P antagonists are used to treat what?

which meds are included in this group?

A

Chemo-induced N/V (CINV).

  • Aprepitant PO (half like of 40 hours)
  • Fosaprepitant IV
  • Rolapitant PO/IV(half life of 180 hours)
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34
Q

Incidence of PONV is greater than ______% following balanced anesthesia

A

50

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35
Q

Opioids cause PONV by their effects on what?

A

The chemoreceptor zone (CTZ) in the area of the postrema of the brainstem

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36
Q

Movement (moving the patient, transport to the PACU) can cause N/V due to:

A

increased sensitivity of the vestibular system

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37
Q

The CTZ contains what receptors?

A
  • Opioid
  • seretonin (5HT3)
  • histamine
  • dopamine (D2)
  • muscarinic acetylcholine receptors.
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38
Q

which three organs send neural projections to the vomiting center in the medulla?

A
  • CTZ
  • Vagal nerve
  • Vestibular
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39
Q

Some of the Opioid-free anesthesia meds include:

A

Exparel
Magnesium,
Lidocaine IV
Ketamine infusion
Propofol infusion
Antiemetics
NSAID,
Tylenol,
Gabapentin,
Celebrex

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40
Q

Enhanced Recovery After Surgery (ERAS) meds includes:

A

TIVA
Ketamine, Precedex, Lidocaine, Magnesium
Regional Anesthesia/Transabdominal Blocks (TAP block)
Gabapentin, Celebrex, Robaxin
IV or PO Tylenol
NSAIDs
Exparel (liposomal bupivacaine)

they can have opioids

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41
Q

Clinical considerations for an ERAS patients:

A
  • No NG tubes
  • Carbohydrate rich clear drink allowed up to 2 hours before surgery.
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42
Q

How the body regulates temperature

A

Thermoregulation

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43
Q

Thermoregulation is a 3 - phase process:

A
  • Afferent thermal sensing
  • Central regulation or control
  • Efferent responses
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44
Q

Autonomic responses to heat:

A
  • Sweating and active cutaneous vasodilation.
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45
Q

Sweating is mediated by:

A

postganglionic cholinergic nerves.

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46
Q

Autonomic response to cold:

A
  • Cutaneous vasoconstriction mediated by alpha-1 adrenergic receptors
  • Synergistically augmented by hypothermia-induced alpha-1 and 2 receptors
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47
Q

4 mechanisms of Heat Loss

A

Radiation
Conduction
Evaporation
Convection

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48
Q

1 source for heat loss

A

Radiation

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49
Q

what is Radiation?

acoount for how much heat loss?

and depends on what?

A
  • Dissipation of heat to cooler surroundings
  • Accounts for greatest patient heat loss (between 40-60%)
  • Depends on cutaneous blood flow and exposed body surface area
  • Head (keep head cover).
50
Q

2 source for heat loss

A

Convection

51
Q

What is Convection?

accounts for how much heat loss?

A
  • Airflow over exposed surfaces
  • Accounts for about 15-30% of intraoperative heat loss
52
Q

What is evaporation?

accounts for how much heat loss?

A

Heat loss through the conversion of water to gas (body perspires)

Accounts for about 8-10% of heat loss during surgery

Major open wound surgery can have significant loss

53
Q

What is conduction?

accounts for how much heat loss?

A

Heat loss through physical contact with another object

Accounts for about 5% heat loss

Contact with a cold surface (bed, mattress)

54
Q

What is the definition of hypothermia?
A. When you look like the guy over there………
B. Core temperature below 36
C. Core temperature below 35
D. When you’re so cold that when you inhale your snot freezes

A

B. Core temperature below 36

55
Q

Which of the following is not an adverse effect of intraoperative hypothermia?

A. Increased risk of infection
B. Increased risk of DVT/PE
C. Increased duration of neuromuscular blockade
D. Increase cardiac morbidity
E. Increased blood glucose
F. Delayed drug metabolism
G. Vasoconstriction
H. Hypertension and tachycardia

A

They are all adverse events!!!

56
Q

Risks of Hypothermia in the Surgical Patient:

A
  • Wound infection and delayed healing.
  • Increased O2 consumption through shivering.
  • Increased risk of cardiovascular incidents (triples incidence of VT and cardiac events).
  • Increased rate of sickling in sickle cell patients.
  • Reduced platelet function and impairs activation of the coagulation cascade
57
Q

Patients at high risk for hypothermia:

A

Elderly
Neonates
Intoxicated folks
Certain drugs
Female

58
Q

Why are elderly at risk of hypothermia?

A

decreased subcutaneous fat and alteration in their hypothalamic function.

59
Q

Why are neonates at risk of hypothermia?

A

immature thermoregulatory center and high surface area to body mass ratio, response to shivering is absent (nonshivering thermogenesis).

60
Q

Why are intoxicated folks at risk of hypothermia?

A

vasodilation and depression of their heat regulatory center.

61
Q

Which drugs cause hypothermia?

A
  • vasodilators
  • NSAIDs
  • Phenothiazine
62
Q

If temperature falls from 37 to 35 by how much does the risk of infection increase?

and why?

A
  • 2 - 3 times

because of vasoconstriction leading to:
- Decreased blood and O2 delivery to the wound.
- Decreased superoxide production

63
Q

If Intraop temp falls to 35 degrees it will increase the hospital stay by:

A

2.5 days

64
Q

If Intraop temp falls to 35 degrees it will increase the hospital stay by:

A

2.5 days

65
Q

How can GA lead to hypothermia?

A
  • by Peripheral vasodilation,
  • altered thermoregulation,
  • and inability to generate heat by shivering
66
Q

How can a neuraxial blockade lead to hypothermia?

A
  • Result of sympathetic blockade,
  • muscle relaxation,
  • and a lack of afferent sensory input into central thermoregulatory centers
67
Q

Cold fluids, blood, prep solutions, and exposure can lead to?

A

Hypothermia

Never give anything cold

68
Q

The fall in temperature during general anesthesia follows a characteristic pattern and has three phases:

A
  • An initial rapid decrease of approximately 0.5 to 1.5°C over approximately 30 minutes
  • A slow linear reduction of about 0.3°C per hour
  • A plateau phase
69
Q

describe what happens to the core body temperature after the administration of ANE

A

pt vasodilates and core body temp decreases while peripheral temp increases

70
Q

If the temperature falls from 37 to 35.5, what is the average increase in estimated blood loss (EBL)?

A

500 cc

decreased activity of clotting factors

71
Q

why is ti difficult to see hypothermia of bloodwork/labs

A
  • conflicting date on the temp which labe are run so dont see hypothermia induced coagulopathy on coag panel
  • TEG usually warmed too but doesnt have to be
72
Q

Compared to temperature of 35 degrees, normothermia is associated with a reduction in ________ by 55%

A

cardiac morbidity

73
Q

why is hypothermia bad for the heart?

A

SHAT

  • shivering
  • hypertension
  • arrythmias
  • tachycardia
74
Q

what happens to EKG in hypothermic pt for each:

mild
moderate
severe

A

mild - sinus bradycardia

moderate- prolonged PR & QT anddddd widened QRS

severe - elevation at the junction of QRS and ST known as hypothermic hump/ J wave (Osborne)

75
Q

MAC is decreased ______ per degree C decrease in core body temperature

A

5-7%

76
Q

how do opioids potentiate hypothermia

A

depress voluntary shivering that would generate heat

77
Q

what happens to each in hypothermia:

Liver
Renal
Protein binding
muscle relaxants

A

L- decreased hepatic BF decreases metabolism

R - decreased renal BF and clearance

PB- increases

MR- prolonged

78
Q

During the first hour after induction of anesthesia, core body temperature can drop by 1-1.5 C due to what?
A. The OR is so, so cold you can blow frost rings with your mouth
B. Radiation heat loss from the patient to the air
C. Redistribution of body heat from core to periphery
D. Evaporative heat loss

A

C

79
Q

heat loss order (and %) in children

A
  1. radiation (39%)
  2. Convection (39%)
  3. Evaporation (24%)
  4. Conduction (3%)
80
Q

The temperature in the room should be increased to about _____ before nonfebrile neonates and infants arrive

A

28 degrees C

81
Q

the most common heat loss type in adults in surgery

second most common

A

1st- radiation

2nd - convection

82
Q

How can we prevent or decrease the drop in patient temperature from redistribution after induction?

A

Increasing mean body temperature by Pre-warming

usually requires about 30 minutes to be effective

83
Q

What is the most effective non-invasive method of warming a patient?

A

Forced air-warming blanket

Bair Hugger

84
Q

What is the overall most effective method for warming
a patient (invasive and noninvasive)?

A

Cardiopulmonary bypass

85
Q

Where is the most accurate place to measure body temperature (closest to what the hypothalamus sees)?
A. Rectal
B. Bladder
C. Nasopharyngeal
D. Distal Esophagus
E. Axillary

A

D

86
Q

gold standard for temperature monitoring

A

pulmonary artery (PA)

87
Q

define hyperthermia

A

rise in body temp of 2 degrees C/hr OR core temp> 38 C

88
Q

Describe the incidence of hyperthermia in the OR and its causes

A

uncommon

usually d/t sepsis or overheating due to active warming. MH or other syndromes

89
Q

conditions associated with hyperthermia (6)

A
  1. MH
  2. NMS
  3. pheochromocytoma
  4. sepsis
  5. transfusion reaction
  6. serotonin syndrome
90
Q

symptoms of MH

A
  1. tachycardia/arrhythmias (earliest sign is tachycardia but not specific)
  2. tachypnea
  3. hypercarbia
  4. muscle rigidity
  5. rhabdomyolysis
  6. acidosis
  7. hyperkalemia
  8. skin mottling
  9. profuse sweating
  10. altered BP
91
Q

T or f: Those susceptible to MH have a mutation of the ryanodine receptor that allows controlled release of calcium from SR

A

F – Uncontrolled

92
Q

__% or greater of MH cases are linked to the RYR1 located on chromosome ___

A

70

19

93
Q

In MH, the channel is the RYR1 because it binds to ______

A

plant alkaloid ryanodine

94
Q

MH is inherited as

A

autosomal dominant

does NOT skip generations

95
Q

Associated skeletal muscle diseases of MH

A
  • Central core disease
  • King-Denborough syndrome
  • Multiminicore disease
  • Centronuclear myopathy
  • Congenital fiber-type disproportion * Native American myopathy
96
Q

MH triggered by

A

IAs and SCh

97
Q

the most sensitive and specific sign of MH

A

Increase in end-tidal carbon dioxide during constant ventilation

98
Q

in MH, Generalized rigidity has extremely high________

A

specificity

NOT sensitivity

less sensitive/specific than EtCO2 increase

99
Q

typically in MH, temperature incerases (not commonly higher than ____ degrees Celsius)

A

40

100
Q

what is Hyperkalemic Cardiac Arrest

A

Sudden hyperkalemic cardiac arrest after MH triggering agents in children with undiagnosed myopathy, especially dystrophinopathies, Duchenne or Beckers muscular dystrophy

Not a result of pathophysiologic changes typical of MH, its related to a muscle membrane destruction leading to
hyperkalemia

101
Q

electrolyte findings for K, Ca, and Mg in MH

A

all increase

only thing that decreases is pH and PO2

102
Q

how to prep ANE machine for known/suspected MH risk

A
  1. disable/remove vaporaizers
  2. new breathing circuit/ reservoir bag to y piece and set vent to inflate (10 L/min of FGF for up to 60-90 min/old machines and for 20 min for new machines)
  3. changes CO2 absorbant
  4. attach activated charcoal filters to both limbs of breathing circuit and during prooceudre to reduce vapor concentration to < 5 ppm
103
Q

how to prep OR/supplies for known/suspected MH risk

A
  1. Prep ANE machine
  2. locate MH cart
  3. cover/tape SCh or remove it from med cart
104
Q

alternatives for known/suspected MH risk

A
  1. regional
  2. TIVA
  3. local
  4. N2O
  5. benzos
  6. Narcotics
105
Q

T or F: in the event of an MH crisis, the CRNA should stop anesthetic triggering agents, change the machine/circuit, and increase FiO2

A

F – do NOT change machine or circuit

*ppt slide 68

106
Q

treatments for Hyperkaelmie

A
  • calcium chloride 10 mg/kg IV (max 2000 mg)
  • calcium gluconate 30 mg/kg IV (max 3000 mg)
  • D50 1 amp IV + regular insulin 10 units IV
  • sodium bicarbonate 1-2 mEq/kg(max 50 mEq)
107
Q

if MH occurs, whta should the UO goal be

A

1-2 mL/kg per hour

may give diuretics and fludis

108
Q

in MH crisis, what should you do if CK or urine myoglobin elevated

A

consider alkalinizing the urine

109
Q

What is the dose for Dantrolene and Ryandodex and how are they prepared

A

Dose = 2.5 mg/kg

Dantrolene - 20 mg vial diluted with 60 mL preservative-free sterile water

Ryanodex - 250 mg vial diluted with 5 mL preservative-free sterile water

110
Q

if metabolic acidosis is suspected in MH crsis, administer

A

sodium bicarbonate 1-2 mEq/kg

111
Q

How does Dantrolene/Ryanodex work?

A
  • Direct-acting skeletal muscle relaxant, hydantoin derivative
  • Directly interferes with muscle contraction by inhibiting Ca2+ release from the SR
  • Possibly binds to the RYR1 receptor
  • Can also lower the temp in NMS and thyroid storms
112
Q

The most accurate diagnostic for MH is exposure of biopsied skeletal muscle to ____, _____, and ________.

how is this test performed

A
  • halothane, caffeine, and ryanodine
  • Biopsy from the thigh and suspended in a water bath at 37 degrees Celcius
  • Then exposed to halothane, caffeine or ryanodine
  • Isometric contracture is measured with a strain gauge
  • Threshold and height of contracture is measured, and a diagnosis of MH is based off those measurements
113
Q

biopsy skeletal muscle to test for MH is highly______ and close to____%. ____% of positive results are false-positives

A

sensitive

100

20

114
Q

S/S of NMS

A
  • Muscle Rigidity/rhabdomyolysis
  • acidosis
  • tachycardia
  • Increased temperature
  • Depressed consciousness
  • Autonomic instability
115
Q

medications that cause NMS

A
  • Compazine
  • Reglan
  • Droperidol
  • Phenergan
  • neuroleptics
  • antidopinergics
  • phenothiazines

central dopaminergic blockade at the hypothalamus

116
Q

treatment for NMS

A
  • benzos
  • dopamine agonist (bromocriptine)
  • maybe dantrolene
117
Q

S/S of Serotonin Syndrome

A
  • Mental status changes
  • Autonomic hyperactivity (fever, tachycardia, hypertension, diaphoresis) - Neuromuscular abnormalities (tremor, hyperreflexia)
118
Q

causes for Serotonin Syndrome

A
  • SSRIs
  • MAOI
  • TCAs
  • amphetamines
  • Demerol
  • methylene Blue
119
Q

treatment for Serotonin Syndrome

A
  • Active cooling
  • IV fluids
  • increase the anesthetic depth to decrease autonomic hyperactivity
  • serotonins antagonist (Chloropromazine IV or Cyproheptadine PO)
120
Q

Drugs that can Increase risk for Hyperthermia

A

drugs that increase BMR and heat production
- Sympathomimetic drugs
* Monoamine oxidase inhibitors
* Cocaine
* Amphetamines
* Tricyclic antidepressants

increases temps by supressing sweating
- anticholinergics
- antihistamines

121
Q

How to treat Hyperthermia

A
  • Expose skin surfaces * Cooling blankets
  • Ice packs
  • Cool fluids
  • Antipyretics
  • Treat the cause
  • TURN OFF THE BAIR HUGGER

614 General Principles Of Anesthesia (14 decks)

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